因嚴重侵犯至右心的腎臟腫瘤導致的肺栓塞之案例分享與文獻回顧

李翊維  謝德生

國泰綜合醫院外科部 泌尿科

A severely invaded renal tumor cause pulmonary embolism – Case report and literature review

Yi-Wei Lee   Teh-Sheng Hsieh

Division of Urology, Department of Surgery, Cathay General Hospital, Taipei City, Taiwan

One of the unique features of RCC is its frequent pattern of growth intraluminally into the renal venous circulation, also known as venous tumor thrombus. This growth may extend into the IVC with cephalad migration as far as the right atrium or beyond. The absence of metastases in many patients with vena cava extension is an intriguing aspect of this cancer’s behavior.

A 66-year-old male patient came to our emergency department that complained of abdominal distention accompanied with dyspnea on exertion and poor appetite for 1 week. Tracing back his medical history, he had received percutaneous transluminal angioplasty for pulmonary embolism, catheter directed thrombolysis with EKOS from main pulmonary artery to right pulmonary artery. Furthermore, percutaneous coronary intervention was also performed 1 week later and showed coronary artery disease (2 vessel disease), with drug eluting stent x1 for right coronary artery (1-2), drug eluting stent for right coronary artery (2-3) stent in stent, and drug coated balloon for left circumflex artery (13). This time, chest computed tomography showed pulmonary embolism with thrombus at right pulmonary artery, including segmental branches of RLL; and left pulmonary artery, including its segmental branches of LUL; Extensive thrombus at intrahepatic IVC to right atrium and right ventricle; Extensive thrombus at dilated intrahepatic IVC with non-opacification of hepatic veins. Abdominal computed tomography unveiled a 8.3 cm of abnormal hypoenhancing mass at right renal area and suspect thrombus at enlarged right renal vein and adjacent IVC. He was then admitted to intensive care unit for further management. We urologist was consulted for renal tumor for possible surgical intervention.

Due to right renal tumor with IVC and right atrium invasion, we also invited cardiovascular surgeon for combined surgery of right radical nephrectomy and removal of IVC, right atrium, right ventricle thrombus under cardiopulmonary bypass. The pathological report reported clear cell carcinoma, grade IV with right renal vein, IVC and right ventricle thrombosis. After surgery, the patient was recovered smoothly with only bilateral lower limbs edema. We kept anticoagulant medication diuretics use. He was discharged without any discomfort.

Herein, we reported a patient with pulmonary embolism due to severely invaded right clear cell carcinoma into right atrium, right ventricle, even pulmonary arteries. After surgery, he was recovered smoothly and uneventfully.